Risk Management in Mass Gatherings

Abstract

In this section, risk management in mass gatherings will be addressed. Mass gatherings, due to their nature, fall into the category of unique events since they have the potential for incidents, injuries, and even fatalities. Identifying these potential risks and managing them can help event organizers to prevent accidents. This section of the book, by classifying and introducing threatening risks in mass gatherings, provides a better understanding of the organization of such events and ultimately facilitates the risk assessment process in mass gatherings.

1. Introduction

According to the World Health Organization’s definition, a mass gathering is an event, pre-planned or spontaneous, where the number of individuals is sufficient to strain the planning and response resources of the community at the local, state, or national level. Mass gatherings can occur for various reasons, including religious, social, cultural, political, and sporting events. Mass gatherings are broadly categorized into planned and unplanned (spontaneous) gatherings, each having its own subtypes. This categorization is crucial in the management of mass gatherings because the planning and execution of these events depend on the type of gathering and the conditions of the venue. Depending on the type of gathering, the conditions, and the facilities available, various risks may threaten the participants. Managing unplanned mass gatherings is notably more challenging, and these gatherings pose greater health risks to participants [1].

The safe organization of a mass gathering requires preparedness from various entities involved in its execution, such as the main organizing authority, different health departments, pre-hospital emergency services, regional hospitals, and collaborating sectors like the police and fire departments. Within these, the health sector must ensure readiness in various areas. As the first step in the preparedness plan, each sector should identify the risks associated with its role. After identifying the hazards and vulnerabilities of each event, we can analyze potential risks and design operational plans to eliminate or reduce them. Indeed, each of these events is susceptible to health-threatening risks and has its own specific incidents. Over the past decade, concerns about health-related hazards in mass gatherings have increased [2]. The primary health concerns in mass gatherings include infectious diseases such as respiratory and foodborne illnesses, injuries, traffic accidents, heat-related issues, insect bites, non-communicable diseases, and terrorism [3]. Many mass gatherings have reported high mortality rates due to communicable diseases, non-communicable diseases, injuries from stampedes, and terrorist attacks. In addition to infectious diseases, both endemic and seasonal (resulting from water, food, and respiratory sources), the health system faces challenges such as bruising, lacerations, limb amputations, muscle strains, headaches, dizziness, asthma and respiratory problems, heat-related issues, and abdominal pains that require specialized medical care [4]. In addition, participants in mass gatherings may undergo psychological changes that can have negative aspects, posing risks to their health [5]. Numerous statistics from around the world highlight the multiple injuries resulting from mass gatherings. These unfortunate incidents occur in various types of cultural, sports, and religious events. In addition to causing injuries, these events have also led to fatalities. The primary causes of mortality are often associated with stampedes and trauma [6]. The hazards associated with mass gatherings are related not only to the number of participants but also depend on various other factors. The risks have a direct relation to the existing hazards, the level of exposure, and the vulnerability of the population and the environment [7]. Organizers of mass gatherings must have access to reliable data from various aspects of the event to provide efficient resources and equipment and predict the required personnel in the health sector [8]. The most important step in this regard is assessing the risks of mass gatherings in the pre-event stage. Many injuries resulting from mass gatherings occur due to the lack of a risk management strategy. To prepare for managing mass gatherings and implement preventive measures to reduce risks, in the first step, it is necessary to identify risk factors and conditions that may contribute to health hazards in a mass gathering, creating the possibility for a comprehensive risk assessment. In essence, after identifying the hazards, we can analyze and evaluate them, assessing the likelihood of incidents and their impact on participants. To achieve maximum risks in mass gatherings, the best way is to categorize them based on a scientific methodology. With this approach, we are essentially aiming to develop effective management actions. One such classification is the 5-part categorization, which classifies various threatening risks into five main categories:

1. Environmental hazards

2. Hygiene hazards

3. Psychosocial hazards

4. Individual hazards

5. Management and facility hazards [9].

Understanding the hazards of each category in managing the risks of that category can be very beneficial. The collection of risks from all categories can provide event organizers with a comprehensive and complete overview of risks. In fact, after identifying risks in each category, a general risk assessment for the entire mass gathering can be obtained. For a better understanding of each category and ultimately achieving an overall risk assessment, the threatening risks of each category will be fully explained in this section (Figure 1).

Figure 1.

Five domains of mass gathering hazards.

2. Environmental hazards

This area encompasses risks related to the event venue and weather conditions during the gathering. These risk factors include the number of participants and population density, moving crowds, hot weather air humidity, wide dispersion (large distances) in uneven environments, the likelihood of traffic accidents, rainfall, cold weather, outdoor gatherings, gatherings without clear boundaries, drowning incidents, insect bites, and sunburn. The larger the number of participants in a gathering, the greater the need for planning. As the population density increases, the likelihood of risks related to stampedes and associated traumas also rises. According to studies, between 1980 and 2007, 215 different human stampede incidents led to 7069 deaths and 14,000 documented injuries worldwide. With 965 people reportedly killed during a religious gathering in Baghdad in 2005, it was the deadliest stampede of its kind in the previous century. A total of 380 pilgrims lost their lives in the human stampede that occurred in Mina Valley during the 2006 Hajj. Only in the year 2015 occurred another human stampede during the Hajj, which tragically lost the lives of 769 pilgrims [10].

A study on the mass gathering of Hajj in 2018 showed that there were referrals to relief centers with different degrees of hyperthermia between 11:00 AM and 2:00 PM. In addition, people with old age and underlying diseases have a higher risk of hyperthermia [11]. A modeling study on 79 mass gatherings showed that the environmental heat index is one of the important factors in increasing the patient presentation rate (PPR) in mass gatherings [8].

Holding a mass gathering in extremely cold or hot weather increases the risks. In colder weather, the use of heating devices is necessary, which itself requires safety measures. In very hot weather, the risk of heat-related illnesses such as heatstroke increases. Additionally, participants’ need for safe drinking water will be higher in these conditions.

2.1 Solutions and measures to reduce environmental hazards

One of the first steps organizers of mass gatherings should consider is estimating the number of participants based on the available space. Additionally, the entry of individuals into the gathering venue should be regulated through specific gates. Restriction on the entry of vehicles into the gathering area should be clearly defined at a specified boundary to minimize the risks associated with traffic accidents.

The facilities available in the venue or the environment of the gathering place should be proportional to the number of participants and accommodated at the event site. The population density needs to be estimated, and facilities should be strategically placed throughout the gathering location based on this density to ensure adequate coverage.

In gatherings held in open environments, especially those involving walking, it is essential to have designated rest areas with shade and access to clean water at specified intervals. If the gathering takes place near a river or lake, access to it should be restricted or prohibited to prevent the risks associated with drowning [9, 12].

3. Hygiene hazards

This area encompasses significant hazards that have the potential to pose risks to all participants and even the entire community. These risks include the outbreak of diseases, the hygiene quality of food and beverages, waste disposal, and wastewater discharge. In fact, this domain highlights risks that may have future consequences for the entire society, including epidemics of respiratory diseases that may occur after the mass gathering in the community.

In addition, due to the lack of adherence to hygiene requirements related to food and water, outbreaks of gastrointestinal epidemics may also occur. In gatherings, especially those lasting more than one day, negligence in proper waste disposal and sewage can pose environmental hazards to the region. Lack of health supervision in the preparation and distribution of food is another risk in this area. A 15-year retrospective study on the spread of meningitis in mass gatherings has shown that these gatherings have a high potential for the spread of infectious diseases, although the development of a vaccine to prevent this health problem has been helpful [13]. Also, in mass gatherings held in the United States, the spread and transmission of respiratory diseases such as influenza have been reported. This concern is also present in international gatherings about more diseases such as measles and mumps [14]. The outbreak of food poisoning is one of the concerns that has been observed in mass gatherings. In one case in India, 291 people with symptoms of diarrhea, abdominal pain, fever, chills, and vomiting went to the hospital due to food poisoning within a few hours after the gathering [15]. During the spread of the COVID-19 pandemic, it was shown that due to the possibility of the virus spreading in mass gatherings, the death rate caused by the virus increases in events [16].

3.1 Solutions and measures to reduce hygiene hazards

One of the most important solutions to reduce the risks related to the health sector is the design of a patient tracking and surveillance system. Based on the potential diseases that may cause an epidemic in mass gatherings, a surveillance system should be adjusted. The syndromic care system helps the organizers to identify people who have symptoms of respiratory, gastrointestinal diseases, etc. The distribution of food and water should be done under the supervision of health inspectors who are approved by the organizers, and the distribution of food and water from unreliable sources should be prevented. Health inspectors must have the necessary authority and responsibility to cancel the distribution of foods that are suspected from a health perspective. In planned gatherings, the venue for the gathering should be planned for standard collection of sewage and waste from a hygiene perspective. Another aspect to consider in this area is preventing the presence of street vendors in large gatherings because dealing with the distribution of food items by vendors can be very challenging. Additionally, the presence of street vendors in mass gatherings increases the possibility of terrorist and bioterrorist attacks [17, 18].

4. Psychosocial hazards

One of the factors that can turn a mass gathering into a severe incident with multiple casualties is the behavior of the crowd. Before organizing a large gathering, the crowd behavior should be determined based on the type of gathering. In gatherings accompanied by the excitement of participants, there is a higher possibility of risks. For example, confrontational gatherings where two opposing groups organize it together, election campaigns, or sporting events held in stadiums fall into this category.

In gatherings where alcohol consumption is possible, the risks in this area are highlighted because the crowd has the necessary behavioral potential for various risks. Another risk related to this area is the possibility of widespread rumors in gatherings. The spread of rumors among the crowd may lead to changes in crowd behavior, overcrowding, and pose health risks to the participants. Reported from sporting and music MGEs demonstrated that, drug and alcohol usage lead to intoxication, aggression, and serious injuries [19]. In addition to the behavior of the crowd, one of the other important factors in the psychological field of mass gatherings is the mood of the crowd. Identifying population mood is more difficult than identifying population behavior because it is often invisible. The mood of the population is divided into three levels: passive, active, and energetic. The more the mood of the population is toward the energetic level, the higher the probability of risks [20].

4.1 Solutions and measures to reduce psychosocial hazards

Some measures related to reducing these hazards need to be taken before holding the gathering, and some actions should also be carried out during the event.

Before the gathering, the type of event and the behavior of the crowd should be anticipated, and special facilities for it should be planned at the event venue accordingly. During the gathering, the behavior of the crowd, the level of excitement, and the potential for crowd confrontation should be monitored, and if any slight changes are observed, necessary interventions should take place. Before the gathering, laws related to alcohol consumption restrictions or prohibitions should be communicated to the participants. It is recommended that cameras responsible for monitoring the crowd during the gathering be equipped with operators trained in crowd behavior analysis. These operators should report any changes, congestion, or excitement observed during the event. To prevent the spread of rumors and the creation of anxiety among the participants, multi-layered communication should be carried out. This communication can be done through monitors, loudspeakers, or paper announcements. Timely and comprehensive communication will create confidence among participants and prevent emotional behaviors [9, 21].

5. Individual hazards

This area essentially reflects the general characteristics and demographics of participants in mass gatherings. The risks in this area increase as participants in mass gatherings come from vulnerable population groups. The presence of the elderly, children, and women in mass gatherings increases the required facilities for the event. Involving individuals with illnesses or disabilities and limited mobility in mass gatherings will face higher risks in this area. However, it is not possible to prevent the presence of these individuals in gatherings. Considering the nature of gatherings, which may involve recreational, social, or cultural activities, the presence of these individuals is unavoidable.

5.1 Solutions and measures to reduce psychosocial hazards

The first step in reducing such risks is to create a comprehensive profile of the population of individuals participating in the gathering. This action should be undertaken before the gathering by identifying and registering participants. Based on this profile, specific facilities may be added to the location of the mass gathering. Considerations such as wheelchair access, additional seating areas, and increased spacing for the crowd are among these measures. For gatherings that last more than a day or several days, providing medical and pharmaceutical needs for sick and elderly individuals should be mandatory.

6. Management and facility hazards

The risks arising from this area include improper planning, insufficient organizing personnel, inadequate facilities, and improper placement of facilities. For example, the lack or shortage of healthcare personnel at the gathering site (doctors, nurses, firefighters, police, and emergency medical workers), neglect of security and the potential for terrorist attacks, the absence of directional signs, failure in risk assessment, lack of communication, lack of pre-incident warning, absence of vaccination programs, lack of collaboration among agencies, difficult access to healthcare services, scarcity of medical service resources, challenging access to water and food, availability of alcohol, absence of free water, and the organization of gatherings for an extended period. Each of these risks has a high potential for causing incidents with a large number of casualties. Mass gatherings, given their nature, require planning similar to what happens in emergencies and disasters. In these gatherings, various organizations with different missions must work alongside each other. In this context, the unity of command and communication appropriate to the incident are crucial [9]. Statistics extracted from the Global Terrorism Database (GTD) over the last 50 years show that the number of terrorist attacks has increased in recent decades. These attacks have been carried out with various weapons in various music, sports, religious, and political festivals. These attacks in mass gatherings have killed hundreds of people and injured thousands of others [17].

6.1 Solutions and measures to reduce management and facility hazards

The most crucial step in this area is risk assessment before organizing a mass gathering. All potential risks, including those mentioned in previous areas, should be assessed, classified, and managed before conducting the mass gathering. Without conducting a risk assessment, any action taken will be blind and non-purposive.

In this area, it is essential to estimate the facilities and personnel required for organizing a mass gathering. This estimation depends on the results of the initial risk assessment. Another important category in this area is the placement of facilities and employees who provide services. This is particularly crucial, especially for emergency response personnel and healthcare service providers. In the event of an incident and the participants’ need for medical services, both access to the target population and the evacuation of injured individuals are vital.

Access routes to the population and methods of transporting injured individuals to medical centers should be clearly defined and practiced on pre-designed maps. The safe conduct of mass gatherings requires the definition of multiple communication layers to establish effective communication among all organizing entities in the gathering. Due to population overload, the use of conventional communication systems such as mobile phones in mass gatherings may come with challenges. Therefore, organizers should equip themselves with alternative communication layers, such as using wireless communication, monitors, displays, and audio alerts at international gatherings should be compatible with the languages of the participants in the gathering.

In addition, in international gatherings, attention should be paid to the cultural differences among participants in mass gatherings. Warnings, educational programs, and executive plans should be designed in accordance with different cultures. In events that last more than a few days, a well-thought-out program for educating participants before the event is essential.

The Incident Command System (ICS) should be planned and practiced in advance. Individuals serving as responders in mass gatherings need to be familiar with their roles and responsibilities outlined in the ICS. This requires conducting multiple exercises and drills in the pre-event phase before the event takes place [9, 22]. In order to hold safe and create the necessary coordination between all service providers in mass gatherings, it is necessary to use an integrated management system, just like natural disasters. The implementation of the public health emergency operation center (PHEOC) is one of the necessities [23].

6.2 Opportunities for conducting mass gatherings

Despite all the risks that threaten the health of participants in mass gatherings and the potential for various incidents to occur, organizing these gatherings also presents numerous opportunities for the organizers. Many planned programs for handling incidents and disasters are executable and assessable during conducting the mass gatherings. Implementing an incident command system as the primary management structure during incidents at mass gatherings, making it feasible and evaluable.

Communication systems not commonly used in normal situations, such as wireless communication and satellite phones, can be utilized and evaluated during the execution of mass gatherings. Collaborative work and coordination between departments are inevitable during mass gatherings, enhancing organizations’ capabilities in this regard. Some existing processes of organizations may require fundamental changes during incidents. These processes can be practiced, assessed, and revised during the execution of mass gatherings. Performing mass gatherings sometimes necessitates the establishment of additional infrastructures in the host community. These developed infrastructures can contribute to the overall development of the hosting community. This is particularly advantageous in cities and communities with lower levels of development, providing a golden opportunity for improvement.

7. Conclusion

Mass gatherings are organized for various social, cultural, and religious reasons, primarily aimed at providing entertainment in society. However, for various reasons, they have the potential to turn into an incident. Therefore, the organizers of these gatherings must conduct a comprehensive assessment of potential risks and, based on that, identify and reduce the identified hazards as much as possible. They should also anticipate the necessary facilities and human resources required for organizing mass gatherings. This section of the chapter provides a classification of threatening risks in mass gatherings and details each category, offering organizers the opportunity to identify these risks. In addition, each category includes proposed solutions to assist in managing and reducing these hazards.